The role of film in maternal health communication in
low-income countries
An analysis of ‘Di Kombra Di Krai (Cry of a Mother)’
– a maternal health drama in Sierra Leone
Josie Eve Gallo (AI6593)
Communication for Development One-year Master’s
Cover letter for examiners Amendments to final submission:
● Changed phrasing of first research question (and discussion therein) from ‘tool’ to ‘medium’
● New paragraph on medium of film on page 8 ● Added chapter numbers and sub-chapter numbers
Abstract
Maternal mortality rates in low-income countries remain high and almost two thirds of global maternal deaths are in sub-Saharan Africa (WHO, 2019). Communications interventions such as media and entertainment education initiatives could help improve maternal health outcomes. The aim of this research is to explore this area further; focusing on the case study of ‘ Di Kombra Di Krai (Cry of a Mother) ’, a maternal health drama produced in Sierra Leone in 2020. The research utilises interviews with key stakeholders in the production, and content analysis, to understand why film is an appropriate medium of communication for maternal health, the processes involved, and the benefits to the participants. This research aims to provide further information that will be beneficial for communication for development professionals and organisations on the role of film in maternal health communication in low-income countries.
Glossary of terms
Future View Film Group = FVFG Purple Field Productions = PFP
Di Kombra Di Krai (Cry of a Mother) = DKDK NGO = Non-governmental organisation
Traditional Birth Attendant = TBA Entertainment education = EE
Disclaimer
I have previously worked with PFP in 2013, but have not worked with FVFG and was not involved with the production of DKDK. I have also previously worked with an organisation mentioned elsewhere in this research, Medical Aid Films (employed from 2014 to 2017), and am currently employed by Peripheral Vision International.
Acknowledgements
I would like to thank the following people for their support in this research:
Future View Film Group -
Mohamed Special Conteh Karim Kargbo
Mariatu Kamara
Chernor Mustapha Thoronka
Purple Field Productions -
Elspeth Waldie Kevin Waldie Rick Elgood
Zoe Vowles, King’s College London
Dr Foday Sesay, Ministry of Health and Sanitation in Sierra Leone Dr Paul Falzone, Peripheral Vision International
Helen Coombe, Medical Aid Films
Michael Hill, London School of Hygiene and Tropical Medicine Martin Long
Abby Samuel Madeleine Kelly
And the Communication for Development staff at Malmö University; particularly the supervisor for this research, Joshka Wessels.
Table of contents Abstract p1 Glossary of terms Disclaimer Acknowledgements p2 Chapter 1: Introduction p5 1.1 Research questions p6 Chapter 2: Background p7 2.1 Sierra Leone p8
2.2 Future View Film Group and Purple Field Productions p10 2.3 Di Kombra Di Krai (Cry of a Mother) p11
Chapter 3: Literature review p13
3.1 Communication for development p13 3.2 Media for development p14
3.3 Media development p15
3.4 Participatory communication p17 3.5 Entertainment education p18 3.6 Health communication p20 3.7 The use of film in health communication p20
Chapter 4: Theoretical framework p22
4.1 The rhetorical change model in drama p23 4.2 Participation Schemas p25
Chapter 5: Methodology p27
5.1 Interviews p27
5.2 Content analysis p30
5.3 Reflexivity p31
Chapter 6: Results and analysis p32
6.1 Why is film an appropriate medium of communication for maternal health in
Sierra Leone? p33
6.2 What are the production processes involved in creating a maternal health
drama? p39
6.3 What are the benefits for those involved in producing a maternal health
drama? p46 Chapter 7: Conclusion p51 7.1 Further research p52 7.2 Closing thoughts p53 References p54 Additional reading p59 Appendix p62
Appendix A: FVFG and PFP documents p62 Appendix B: Interview guide p62 Appendix C: Interview consent form template p64
Chapter 1: Introduction
In sub-Saharan Africa the risk of maternal death remains high; 1 in 38, compared to 1 in 3700 in high income countries (WHO, 2015). UNICEF notes the importance of communication strategies within maternal health; ‘to increase knowledge, and to change attitudes, behaviors, and social norms at the individual, community, and societal levels are essential to decreasing the risk and incidence of, and mortality, morbidity and undernutrition of mothers’ (2016, p6).
There are a small number of organisations producing content on maternal health aimed at audiences in low-income countries, undertaking media for development and entertainment education initiatives. This is important in the field of Communication for Development, as these are initiatives that aim to improve health outcomes (in line with the Sustainable Development Goals) through the use of communication and media. Due to growth in access to media and technology in low-income settings around the world, this is an expanding area.
This particular case study of ‘ Di Kombra Di Krai (Cry of a Mother)’ (DKDK) was selected for
the following reasons; it is a collaboration between a UK NGO, Purple Field Productions (PFP) and a local filmmaking group, Future View Film Group (FVFG) in Sierra Leone, rather than a film that was solely produced by a Western NGO; it employed the use of drama rather than other NGOs that are producing factual content; and finally as noted in the disclaimer, I have previous links with PFP which provided access to the key stakeholders involved in the production of the film.
The research originally intended to give focus to the distribution and dissemination of the film, by observing film screenings in-country and analysing audience response. However due to the COVID-19 pandemic this was not possible for several reasons; international travel was not permitted, large gatherings of people were not allowed during Sierra Leone’s national lockdown, and the lockdown impacted FVFG’s schedule so the post-production stage and distribution of the film was delayed. Therefore I decided to focus on the production process itself; which led to the research questions below.
1.1 Research questions
From reflecting on the main research question, and through supervisor discussion, the following research questions were identified:
Why is film an appropriate medium of communication for maternal health in Sierra Leone?
This first question explores the context of Sierra Leone, the barriers within maternal health, and the suitability of health communication through film.
What are the production processes involved in creating a maternal health drama?
This question aims to break down the processes used in producing maternal health content, and to identify strengths and weaknesses.
What are the benefits for those involved in producing a maternal health drama?
Finally, the research explores the benefits for participants who produce maternal health communication initiatives - including secondary benefits for the communities involved.
Chapter 2: Background
There have been some major improvements in the maternal health landscape since the Millenium Development Goals were set; WHO (2014) notes that there was a 45% decrease in maternal deaths between 1990 and 2013, however maternal health is still a key issue in many low-income countries.
The Sustainable Development Goals (n.d.) set new targets for maternal health - Target 3.1 is to ‘reduce the global maternal mortality ratio to less than 70 per 100,000 live births’. The Maternal
Health Task Force (n.d.) notes that the reasons for poor maternal health indicators are often complex and consist of multiple factors: ‘Social determinants such as place of residence, socioeconomic status and race/ethnicity as well as institutional factors such as national resource allocation, health system infrastructure and political accountability for evidence-based programming’.
Many maternal health organisations refer to the ‘Three Delays’ model, a framework by Thaddeus and Maine (1994), which describes three key factors in maternal mortality: a delay in decision to seek care; a delay in reaching care; and a delay in receiving adequate health care.
With regards to the first delay, examples of the factors that inform the decision to seek care include ‘the actors involved in decision-making; the status of women; illness characteristics; distance from the health facility; financial and opportunity costs; previous experience with the healthcare system; and perceived quality of care’ (Thaddeus and Maine, 1994, p1092).
Maternity Worldwide (n.d.) recommends that this is addressed partially by ‘ providing
communities with information on pregnancy, childbirth and newborn health care so they know when to seek medical help’.
Jacoby, Brown, Bharath Khumar, Rimal and Velu note that ‘for millennia, people have been
telling parables or stories to teach lessons ’ (2014, p84). The medium of film (and in particular, drama) with its roots in traditional storytelling, has the benefit of being widely accepted as a cultural form.
Scott states that the ‘media for development approach fails to address the broader structural drivers of poverty and inequality’ (2014, p29). Whilst communication for development
initiatives cannot solve practical issues around health facility resources and a shortage of health professionals, they can promote life-saving health messages to communities around safe pregnancy and birth, and help to dispel myths and misconceptions. With regards to the ‘Three Delays’ model, communication and media for development initiatives could potentially address the first delay of deciding to seek care.
2.1 Sierra Leone
Sierra Leone has one of the highest maternal mortality rates in the world, where the lifetime risk of dying in childbirth is 1 in 17 (Mason, 2016). ‘ To place this figure in historical context, UK parish records show better odds for English mothers in the early 1700s ’ (Young, 2016). FVFG
noted that they titled the film because ‘mothers have always cried in our country - that’s what we want to reduce’ (personal communication, 5/11/20).
One major factor is the shortage of health workers following the Ebola outbreak in 2014 - ‘estimates that the reduced number of health personnel after the epidemic could cause maternal mortality to increase by 74 per cent ’ (Mason, 2016). Similar to the Ebola crisis, there are concerns that the COVID-19 pandemic could further increase maternal mortality in low-income settings, in part due to pressures on health systems and an increased fear of health settings (Roberton et al, 2020).
Many women in Sierra Leone still deliver at home with Traditional Birth Attendants (TBAs) rather than attend health facilities, despite this healthcare service being free of charge. In part this is because TBAs are a vital cog in the maternal health wheel and they are often trusted by the community. This means that they have the potential to receive training to increase their knowledge and skills (Whitaker, 2012).
BBC Media Action undertook research to explore the role of communication in community health in Sierra Leone, noting only 25% of women and 51% of men are literate (Wittels, 2016,
p11). The research, which surveyed communities across the country’s 14 districts, found that there is a strong interest in health information - 86% of respondents indicated that they wanted to receive more information on health (Wittels, 2016, p16) and 61% of women of reproductive age were interested in receiving more information on pregnancy (Wittels, 2016, p21). The diagram below shows the different ways women seek information about pregnancy.
Figure: Communication networks - health communication and health-seeking behaviour of mothers in Sierra Leone (Wittels, 2016, p26)
As mentioned above, one of the challenges faced in maternal health is the use of TBAs and traditional medicine. However, instead of this being viewed as a barrier to seeking and engaging with health information, the research notes the importance of traditional and formal medicine being promoted as harmonious. TBAs are ‘ seen to be the most knowledgeable and experienced on the subject of childbirth and pregnancy’ (Wittels, 2016, p23) and communication efforts
‘should bring informal providers on board… the Ministry of Health and Sanitation has, for example, encouraged TBAs to adopt a non-delivery role as maternal health promoters who provide advice and refer pregnant women to clinics’ (Wittels, 2016, p36).
Another barrier is the cost of accessing care, and that financial decisions are often made by the male partner who may not be engaged in the importance of safe delivery; ‘ Men explained that
they make the final decision on whether to seek help for adult healthcare because it usually involves cost and they alone decide how household money is spent ’ (Wittels, 2016, p25). Whilst
giving birth in a facility in Sierra Leone is free of charge, there may be other costs involved in terms of transport or medicine.
The research also notes the importance of building on experience of communication during the Ebola crisis, ‘which illustrated that bottom up communication facilitates positive change’ (Wittels, 2016, p10) and that communication efforts ‘should equip communities with actionable
information - communities are more likely to implement health information if it is easy, cheap and quick to implement’ (Wittels, 2016, p10).
2.2 FVFG and PFP1
The main case study for this research is FVFG, a collective of filmmakers in Makeni, in the north of Sierra Leone. They began as a theatre group creating educational dramas, but felt they could increase their reach through the use of film. FVFG also received training support from WeOwnTV, a media learning centre in Sierra Leone - an initiative funded by a US organisation, Mirabel Pictures. In 2013 they started to receive support from a small UK NGO, PFP, who specialise in working with local filmmakers in Africa and Asia to create educational films. PFP provided film equipment, training and mentoring to the group. FVFG have since produced a range of educational content, and were particularly responsive during the Ebola outbreak in creating health material. Over the years, FVFG have increased their production remit and gained attention both nationally and internationally (‘FVFG history’).
As part of their production work, FVFG disseminate films in rural settings through the use of a portable, solar-powered cinema kit. The team have developed the skills to facilitate post-screening discussions with the audience, asking questions about the issues that were present in the film.
Image: Portable cinema kit in action (PFP, 2019)
2.3 DKDK
In 2019, FVFG approached PFP for support on a new production; a drama on safe motherhood; ‘we believe that there is a valuable contribution that can be made through education of both parents and of the community at large, and that this could be achieved, in part at least, by means of film’ (‘FVFG proposal’).
The group planned to ‘ increase understanding of issues relating to pregnancy’, by producing a ‘popular and memorable drama that will attract an audience and trigger discussion, drawing
stories and experiences from real life’ (‘FVFG proposal’). The group undertook background
research on the need for education on maternal health and the potential impact of a film with local health NGOs and hospitals, and received a positive response to the concept (‘FVFG health research’).
PFP provided support through funding of the film’s production budget (approximately £8500 GBP) and through mentoring the production process, from the script writing to the editing. This funding was from PFP’s internal budget and was unrestricted.
The film was shot at the end of 2019. Post-production was delayed due to the COVID-19 pandemic, which halted FVFG activities, but was eventually completed in the autumn of 2020. At the time that this research took place, distribution had not yet commenced.
Chapter 3: Literature review
The literature review for this research started with key communication for development reading: Manyozo’s Media, Communication and Development: Three Approaches (2012) and Scott’s
Media and Development (2014). These core texts provide an overview of models within the communication for development field, which underpin the research analysis.
The review then focused on two specific areas within communication for development relating to the chosen case study: 1) entertainment education (EE) and 2) health communication.
Within EE, the literature review aimed to identify texts which focused on health and low-income countries. Within health communication literature, a specific search was undertaken of journal and academic research papers that focused on the use of film to convey health messaging in low-income settings.
In undertaking this literature review, I was mindful of including a diverse range of texts, including those written by researchers in low-income countries to ensure a range of views.
3.1 Communication for development
First of all, the review undertook an exploration of the different models presented within the communication for development field.
Manyozo rejects ‘communication for development’ as a term, and instead defines it as ‘ media,
communication and development’ (2012, p1). Manyozo describes the ‘six schools’ of
development communication, and how these schools have generated three approaches; media development, media for development, and participatory or community engagement - these have ‘emerged separately… [and] continue to co-exist’ (2012, p1).
Scott however embraces communication for development as one of three strands - the other two being media development, and media representations of development. Within the first strand he defines ‘media for development’ and ‘participatory communication in development’ (2014, p3).
The case study in this research includes elements of three of these models - media for development, media development, and participatory communication; so the literature pertaining to these is relevant.
3.2 Media for development
Scott defines media for development as ‘the strategic use of the media as a tool for delivering positive change in individuals knowledge, attitude and practice in order to achieve development results’ (2014, p13). Similarly Manyozo describes the model as ‘facilities for informing, educating and sensitising people about development and pertinent social issues’ (2012, p54).
Scott (2014) identifies five defining features of media for development (p15): the first is information provision - the idea that ‘ information is linked directly to behaviour change’ and that
the benefits of mass media are that it can ‘ reach relatively very large numbers of people very quickly, repetitively, and inexpensively’ (p16). The second is the cultivating of appropriate attitudes; ‘the belief that culture and individual attitudes are a key determinant of development’
(p17) and that media can ‘challenge traditional norms and values’ (p17). The third is assumptions about communication, audiences and behaviour change - wherein communication is viewed as largely linear (p18) and audiences are seen as passive consumers (p20). The fourth is that change is ‘ planned, controlled, targeted, measurable, predictable, and managed by external change agents’ (p20) - Scott states that this factor, ‘narrow conceptualization of change’ (p21) is ‘most obvious in the ways in which media for development for projects are usually evaluated’
(p21). Finally, an instrumental view of participation - that media for development should note the ‘importance of understanding local context and involving communities’ (p21-22) and that
participation should be viewed as a ‘ means rather than an end’ (p22) - a focus on the process rather than the product. These components provide a useful lens for analysing the efficacy of the case study in delivering a media for development initiative.
Scott is keen to take a critical approach on media for development and its limitations as ‘ it is
often presented entirely unproblematically’ (2014, p14). For Scott, these criticisms fall into two
main categories: the role of social structures, and modernization. With regards to modernization, Scott states that ‘media for development can promote a Western vision of modernity’ (2014,
p34). This is important to note as the case study focuses on a Western NGO (PFP) working with a local media group (FVFG). Their involvement and influence as a Western organisation is discussed in the analysis.
3.3 Media development
Media development is defined by Manyozo as ‘ supporting and building the capacity of media policies, structures and ownership’ (2012, p17). Scott notes that ‘developing the media is perceived as a necessary condition for other social goals to be achieved ’ (2014, p93). Manyozo
includes a wide range of activities under this umbrella, including the training of media professionals and development of community media (2012, p18). Scott recognises that media development covers a vast scope and notes that definitions ‘ collapse all aspects of the media environment into one term… this unhelpfully obscure the various roles that different media can perform’ (2014, p97).
Both Scott and Deane write on the blurred boundaries of media development with media for development, and the tensions between the two. Scott notes that ‘one of the tensions is whether it refers to an end in itself or whether it refers to the means to another end ’ (2014, p93), and that
media development is ‘ conflated with other ultimate outcomes’ (2014, p93), whilst Deane states that ‘clear categorization of what is media development and what is communication for development is often problematic ’ (2014, p228). Deane argues against the need to have strict definitions for the two fields (2014, p239) whereas Scott notes ‘preserving and explaining this
distinction is a vital part of understanding the various potential roles that the media have to play in international development’ (2014, p94).
Manyozo (2012) examines the media development model through different development lenses - when looking at it through a multiplicity paradigm of development, the benefits include
democratisation of communication (community media), and the emergence of ICT for development which has improved media access and participation (p23).
Manyozo discusses two strands of media development - 1) community development and 2) good governance (2012, p115). The first strand is relevant to the case study in this research as it focuses on a community media initiative. Manyozo states that this ‘promotes community
engagement and empowerment’ (2012, p115) and ‘provides an opportunity for media projects to be implemented with the aim of promoting national or local development goals’ (2012, p150).
All three authors note their criticisms with the connection between media development and Western influences. Manyozo notes that media development is often viewed as top down, and ‘focuses on scaling up Western-like media systems, structures and professional values’ (2012, p23). Similarly Deane states that organisations such as BBC Media Action ‘ are often perceived
as advancing a European model of media development ’ (2014, p228). The case study in this research incorporates media development as PFP provides media training to FVFG, and the literature around power and Western influence is relevant in analysing that relationship as PFP are a Western NGO.
They also express concerns around media development funding. Scott writes that there is a focus on international donors driving media development initiatives which ignore local initiatives (2014, p96). Manyozo is in agreement; ‘ the design and implementation of most global media development initiatives are strategically led and funded by Western governments and development institutions’ (2012, p114). Deane states that this funding position has led to ‘concerns that media is increasingly being co-opted by a development sector who have the funds to determine content’ (2014, p229). Manyozo notes the challenges regarding sustainability of these initiatives, stating that they ‘contribute to overdependence on external aid and inequality in the political economy of international communication ’ (2012, p149). This area is relevant to the case study in terms of its funding model, and is explored further in the analysis.
Finally, both Scott and Manyozo emphasise that media development initiatives should be used to bridge the digital divide. Scott describes the barriers to communication and states that these
barriers should be reduced by ‘broadening popular access to the media, participation of non-professionals in content and message production, development of alternative, participation of the community and media users in management and decision making, and decentralisation of the mass media’ (2014, p122). Similarly Manyozo writes on the problems of poverty, inequality, social exclusion and under-development and stresses that ‘media development initiatives should
be addressing these severe and immediate development conundrums’ (2012, p151).
3.4 Participatory communication
Just as there are crossovers with media for development and media development, there are also overlaps between these and the third model of communication for development; what Scott defines as ‘participatory communication’ and Manyozo defines as ‘participatory communication or community engagement’. Again, these cover a broad range of concepts and Scott notes that participatory communication ‘defies singular definition’ (2014, p47).
Whilst media for development and media development are both generally viewed as ‘top-down’ forms of communication, participatory is the ‘ bottom-up vision’ (Scott, 2014, p49). The case study in this research includes elements of participatory communication due to the nature of how FVFG worked with others - including local communities - to produce DKDK.
This top-down, bottom-up concept is defined as ‘diffusion and participatory models’. Morris writes on these two models in detail and describes them as vertical and horizontal; vertical being the dissemination of information - such as mass media - and horizontal being an exchange across communities, such as grassroots participation via group interaction (2005, p125). Morris notes that diffusion is outcome oriented and focused on behaviour change, whereas participatory is process-oriented and focused on empowerment, equity and community (2005, p125). Despite the differences between the two, Scott emphasises that one cannot exist without the other (2014, p58) and Morris states that both models have ‘knowingly or unknowingly borrowed elements from one another’ (2005, p142).
One of the main benefits of the participatory approach, as noted by Morris, is the assumption that it empowers those involved - ‘ communication is not seen simply as a tool for achieving a particular objective, but as a means of empowering all members of the community to have their voices heard’ (Scott, 2014, p49).
There are also criticisms on the participatory model of communication. Manyozo raises valid points about the power structures between the ‘principals’ and the ‘subalterns’ - ‘ participatory
communication as in grass-roots development is fraught with power contestations ’ (2012, p153).
Similarly, Scott notes that for participatory communication interventions, it is ‘ vital that it doesn’t reinforce existing power relations’ (2014, p49). Often those leading participatory
communication initiatives (the ‘principals’) are Western organisations.
This tension of power between Western and local filmmakers is a topic that has been covered in texts on post-colonialism. Berthe’s research on Jean Rouch in West Africa described Rouch and his films as ‘ bound up with the French colonial project; they emerged as part of and in conversation with it, even as they worked to undo some of its logic ’ (2018, p273). This is relevant to the case study as it demonstrates a wider context of external filmmakers not representing or reflecting local interests in favour of their own motives.
In writing on participatory communication, Manyozo refers to Arnstein’s Ladder of Citizen Participation; a process that demonstrates a scale of participation, from manipulation to citizen control (2012, p157). Prieto-Martín expands on Arnstein’s Ladder, and adds ‘Participation Schemas’ to assess the ‘intensity of collaboration’ (2014, p3). This is important because participatory communication is often tokenistic and this research aims to explore the benefits for the participants in the case study. Prieto-Martín’s adaptation of Arnstein’s Ladder is discussed in the Theoretical Framework.
3.5 Entertainment education (EE)
Scott notes that EE is a ‘ common feature of media for development’ (2014, p95) as does Manyozo (2012, p17). Jacoby et al state ‘t he conscious aim of EE is to grab and hold the
attention of audiences and to purposely increase audience members’ knowledge about an issue, create favorable attitudes, shift social norms, and change behaviour’ (2014, p84). As the case
study utilises the use of drama for delivering its messages, the literature on EE is beneficial in understanding its strengths and weaknesses.
Like media for development, much of the EE literature discusses its roots in social learning theory. Grady, Iannantuoni and Winters describe social learning theory as the belief that
‘individuals choose behaviours to achieve desirable outcomes and that individuals learn about the likely consequences of potential behaviours by observing their social environment ’ (2019,
p2).
EE literature highlights its benefits; Waisbord notes that ‘ Some studies have concluded that EE
strategies are successful in attracting large audiences, triggering interpersonal communication about issues and lessons from interventions, and in engaging and motivating individuals to change behaviour and support changes among their peers’ (2001, p14).
Though its success is touted by many, authors including Grady et al and Waisbord highlight that EE can only be successful at ‘ persuading audiences to adopt new ways of achieving existing goals’ (Grady et al, 2019, p3) and that interventions are unlikely to change existing goals; ‘Deeply ingrained mental constructs, like motivations and values, are difficult to change because they provide the foundation and structure of an individual’s belief system ’ (Grady et al, 2019, p3). Khalid and Ahmed agree on these limitations, stating that EE is mainly ‘ motivational rather
than informational’ (2014, p87).
There are also concerns around the evaluation of EE programmes, notably by Green (2021) who argues that much evaluation is insufficient and that whilst EE can prompt short term change, it ‘seldom changes broad worldviews or core values’ (2021, p3). He dismisses many of the research methods that are used to evaluate such programmes, and states that ‘ we have set our
expectations for EE’s effects too high’ (2021, p3). Waisbord notes that it is ‘problematic to reach comprehensive conclusions about the effectiveness of EE’ (2001, p15).
3.6 Health communication
Health communication has often employed the use of EE - and ‘ has increased tremendously
since the 1970s discovery of the entertainment educational model within radio and television soap operas’ (Manyozo, 2012, p82).
Manyozo refers to the ‘P-Process’ by Johns Hopkins, which is used for the design of health communication progammes. He describes the P-Process as having five components: ‘situation
analysis; strategic design; development and testing; implementation and monitoring; and evaluation and replanning’ (2012, p84). This model acts as a blueprint that can be adapted by organisations and individuals as needed for their context, and by itself does not provide much guidance.
Neuhauser, Syme and Kreps note that health communication programmes have ‘tended to focus on one-way design’ (2014, p227) and write on the benefits of utilising community participatory design of health communication interventions, stating that they are ‘ more successful if they are designed with the close participation of the intended beneficiaries and stakeholders ’ (2014,
p228). They describe a six-step model of participatory design for health communication. This model has similar foundations to the P-Process, whilst incorporating participatory components; such as setting up an advisory committee and undertaking formative research using participatory methods.
With a more specific focus on the use of drama within health communication, Gesser-Edelsburg writes on the use of drama as a rhetorical health communication strategy, describing drama as ‘ a
controlled persuasion system’ (2014, p134). This model is described in further detail in the Theoretical Framework.
3.7 The use of film in health communication
Much of the media for development and EE literature focuses on large scale interventions, such as mass media programmes for television or radio. Therefore the literature review sought out
health communication and EE material that focused on organisations using film in smaller scale settings; mostly studies that dealt with community video initiatives in low-income countries, with the aim of better understanding the benefits and challenges in this area. Several research papers (Mweemba, Coombe and Smith; 2020, Sowa, Warwick and Chase; 2018, Mutanda, Waiswa, Namutamba; 2017, Kumar et al; 2015) were identified as key texts, for their focus on maternal health in community settings in low-income countries. These were limited in number, and locating studies that proved the impact and efficacy of the use of film on any subject in low-income countries was scarce.
All of the selected texts note the success of integrating film into health communication programmes. Mweemba et al discuss the higher attendance at health sessions when film was used (2020, p8), whilst Mutanda et al state that the use of film made health sessions ‘ more
efficient and effective’ (2017, p927).
Sowa et al note the importance of going beyond dissemination - that videos were used to stimulate discussions and the importance of these discussions being facilitated (2018, p812). This again highlights the pivotal role of communal exposure and discussion, in media for development and EE programmes.
These research papers also discussed the benefits of local content; Sowa et al suggest that film is likely to be more successful if ‘c ommunity issues and perspectives are more fully represented’ (2018, p811), whilst Mutanda et al state that ‘ communities are more likely to learn and benefit from this information if it is context specific’ (2017, p924).
Mweemba et al identify the ‘ strong link between women’s education and empowerment and
health outcomes’ (2020, p1) but as described in the Background section of this research, note that it is ‘ strongly influenced by gender power dynamics within households and communities’
(2020, p2). Their research explores the use of film in engaging men on maternal health knowledge and suggests that film can increase male knowledge and involvement. The use of film in engaging men on maternal health was also noted by Kumar et al (2015, p8) and Mutanda et al (2017, p926).
Chapter 4: Theoretical framework
The literature on media for development, media development and participatory communication by Scott (2014) and Manyozo (2012), will underpin the analysis in this research - particularly as the case study sits across all three models, as pictured below.
Figure: Venn diagram of the case study in relation to communication for development models (Author’s own)
From Manyozo and Scott’s literature, there are clear benefits but also challenges with each of the models; that media for development (including EE) can be an effective way of delivering messages, but it is important that it is produced appropriately; that media development whilst having some benefits of improving capacity building for local media industries, is often fraught with issues around Western media influences; and that participatory can be empowering if implemented sufficiently but can often emphasise power contestations.
With regards to the health communication literature, particularly the research papers on the use of film that were identified, this builds a foundation of how film can be effectively applied. The recurrent themes from these texts; that film can embellish health outreach activities and engage audiences, that it transcends literacy and language barriers, the value of local content, and that film can potentially tackle gender and hierarchical barriers, are all useful topics that can be
applied to the analysis of the case study - particularly the first research question of ‘ Why is film an appropriate medium of communication for maternal health in Sierra Leone?’.
This research also draws on EE literature, which provides a foundation on which to analyse the case study in terms of its production processes. Grady et al (2019), Jacoby et al (2014), and Green (2021) have all written succinctly on the successes of EE as well as its shortcomings.
In terms of analysing the production processes utilised in the case study further, whilst the research reviewed the ‘P-Process’ (in Manyozo, 2012, p84), and Neuhauser et al’s community participatory design of health communication interventions model (2014), Gesser-Edelsburg’s rhetorical change model in drama (2014) was selected as most suitable for analysing the case study as it focused on the use of drama in health communication.
4.1 The rhetorical change model in drama
Gesser-Edelsburg (2014) presents the rhetorical change model in drama - ‘ whose purpose is to change existing values, positions, and behaviours on health issues’ (p144). This model
comprises of eight components:
1. The audience’s accepted values and norms: This first stage is about the audience’s position - ‘the dialogue should be conducted in such a way that expresses awareness and understanding of the audience’s values while at the same time integrating the oppositional values if wants to convey to the spectators’ (p145). This could include formative research such as needs
assessments or focus discussion groups with target audiences.
2. The rhetoric of the aesthetic: The second part encourages that drama should ‘attract and cast
a positive light on a subject that might be difficult to address ’ (p145). This includes
3. The spectator as ghostwriter: This part of the model is aimed at giving the spectator ‘the
feeling that the dialogue is directed to him and his world ’ (p145), but also promotes balance
between the writer’s intention and the viewer’s imagination (p147).
4. The mythical layer: This discusses that ‘dramatists should avoid jumping ahead to solutions without giving room to the audience’s fear and urges… and should also avoid raising fears to such a level that the proposed solutions cannot deal with them ’ (p145). This emphasises the
importance of focusing on small interventions and lowering expectations of behaviour change.
5. Identification: This encourages that the ‘character who embodies the value of change’ (p145)
should be one that the audience can identify with, and that drama ‘ should avoid illuminating the
character who carries the change in an ambivalent light’ (p145).
6. Conflict: The component of conflict states that barriers must be presented ‘credibly’ (p146) - similar to the above component of identification; the character’s struggles should be authentic and ‘backed by a meaningful process that is inherent to the plot’ (p147).
7. Demonstration: This component advises that ‘the drama should provide tools to help realise the change process’ (p146) and that it should ‘inspire the spectator with hope and strength’ (p147).
8. Catharsis: The final component states that ‘the spectator’s identification should not be
voyeuristic but reflective’ (p146) and that the drama should ‘encourage the viewer to undergo a cleansing personal journey’ (p147).
Gesser-Edelsburg provides a series of evaluation questions for measuring drama effectiveness based on the rhetorical change model in drama (p147). Both the model and the questions will be a useful background for responding to the research question on the production processes, and analysing the processes utilised in the case study and their efficacy.
4.2 Participation Schemas
For responding to the question on the benefits to those participating in the production process, the literature on participatory communication is relevant in understanding the benefits of participatory and analysing power relations.
Prieto-Martín’s adaptation of Arnstein’s Ladder (2014) was selected as it provides a detailed lens for analysing the interviewee’s responses in their participation in the case study.
Prieto-Martín adds Participation Schemas ‘to indicate the maximum and minimum intensity
levels that encompass the various collaborative intensities that are present in the participatory process’ (2014, p4).
Prieto-Martín defines a series of levels, from ‘Conflict’ to ‘Collaborative Participation’. The detail of beyond ‘ single level of collaborative intensity’ (2014, p4) is useful in discussing the collaboration used in the case study, as it combines those working in different disciplines with different powers, with a common goal of coming together to produce a relevant and appropriate maternal health drama.
Chapter 5: Methodology
This section details the methods used for this research and justifies why they were selected as the most appropriate.
5.1 Interviews
I chose to do interviews in order to obtain information from the key stakeholders in line with the research questions. Brinkmann notes that ‘the qualitative research interview has become one of the most widespread knowledge-producing practices across the social scientific disciplines’
These interview participants were selected as those who had close involvement in the film’s production, and therefore would be able to provide the appropriate insights required for the analysis. I had previous connections with both the PFP and CRM interviewees. There was no previous relationship with the interviewees in Sierra Leone; the FVFG team and the DMO.
I chose to do group interviews with FVFG. Morgan notes that the term ‘group interview’ is ‘synonymous with focus groups’ (2008, p3) and that both interviews and focus groups ‘give the
researcher a potentially large role in determining how the conversation will proceed ’ (2008, p4).
Morgan states that researchers are divided over whether focus groups or individual interviews produce better data; some suggest ‘the presence of others in a group biases what each individual says’ (2008, p5) whilst other researchers argue that focus groups are more effective as the interviewer ‘exerts a large influence’ in an individual interview (2008, p5). I felt that as there was not an opportunity to meet the FVFG team in person and build a rapport with them, and as they have an existing group relationship, that they would feel more comfortable participating as a group rather than individually. I felt that as the participants had worked closely together on DKDK, that the questions around the production processes would spark discussion and allow the research to take a directive approach. This same approach was used for interviewing the two PFP producers together, as they were able to reflect on each other’s answers and build on the discussion.
The method of using interviews can be problematic in achieving a balanced and unbiased response, through the question design and interview style - Brinkmann notes the importance of ‘good questions’ (2008, p4) in achieving effective responses. The questions that were prepared for the interviewees were composed with support from literature (Harvard University, n.d.) after the background research and content analysis had been undertaken, so that I was sufficiently knowledgeable on the subject. These questions can be found in the interview guide in Appendix B.
Whilst the method of interviewing can have ethical implications for both respondent and interviewer (Brinkmann, 2008, p5), this topic is not of a particularly sensitive nature and therefore the risk was relatively low. Informed consent is key, and the purpose of the research
was fully explained to all interview participants. All contributors gave consent, using the form that is in Appendix C.
As noted in the Introduction, I had originally planned to undertake research in-country, including interviews with the members of FVFG and the Ministry of Health and Sanitation staff. Instead, all interviews were conducted remotely, either over Zoom, or in the case of the DMO, via WhatsApp (due to his limited availability). Using Zoom also ensured that the interview recording process was compliant with GDPR guidelines.
There were some downsides of not being able to do interviews in-person, particularly with the members of FVFG - which would have provided more time and a better understanding of the local context. However Archibald, Ambagtsheer, Casey and Lawless note the benefits of using Zoom for qualitative data collection; including convenience, access, time-effectiveness, cost-effectiveness, simplicity and user-friendliness (2019, p4). The research found this to be true, and that it was particularly beneficial for the two medical advisors, who both have demanding schedules. Gray, Wong-Wylie, Rempel and Cook note the advantages of using Zoom to increase accessibility to participants (2020, p1297) which is certainly relevant with regards to the FVFG team and the DMO being based in Sierra Leone, whilst I was based in the UK.
The interviews undertaken on Zoom were recorded, and a transcript was automatically provided via the software, which was an additional benefit. It also meant that the recording process was unobtrusive and not a distraction for the interview subjects which is flagged by Harvard University (n.d.) as a potential barrier.
Thompson discusses the subject of paying respondents and suggests it can be one way of ‘recognising and beginning to equalise power relations’ (1996). I made a decision that whilst the majority of interviewees would be volunteering their time to participate, that the members of FVFG should be reimbursed for their time and expenses - which would have been the arrangement had the research been undertaken in-country, as the team would have supported on logistics. In addition to this the cost of the data to join the Zoom call was a barrier to their participation, as internet charges are high in Sierra Leone.
FVFG and PFP also shared a number of internal production documents, in order to support the research. This included background research documents, distribution and evaluation reports, and confirmation of Ministry of Health and Sanitation endorsement of the film. These can be found in Appendix A.
5.2 Content analysis
As the case study included the production of the film, content analysis was also important; not only to understand the subject better and to inform the interview process, but as a means of responding to the research questions around the appropriateness of film and the production processes involved.
Frey, Botan and Kreps recognise content analysis as a form of textual analysis, describing it as ‘ a
method communication researchers use to describe and interpret the characteristics of a recorded or visual message ’ (1999, p1). On textual analysis, Lockyer notes that ‘a text can never
be completely understood because all readings of texts are socially situated’ (2012, p3). It was challenging to undertake a content analysis of DKDK as I am not the intended target audience, and how I engage with a film will be different to that of a member of a rural community in Sierra Leone. In addition, the film itself is in the Krio language, so a lot of nuance around the storyline and dialogue is lost on me as a viewer.
This study utilises what Frey et al describes as qualitative content analysis, where ‘ researchers
are more interested in the meanings associated with messages than with the number of times message variables occur’ (1999, p3). This includes ‘the content, structure, and functions of the messages contained in texts ’ (1999, p1). In terms of analysing DKDK, I paid particular attention to the storyline and how it incorporated health messages, the narrative arcs and development of the characters, how behaviour change was shown both individually and collectively, and the style and aesthetics of the production.
5.3 Reflexivity
The concept of reflexivity challenges the view that knowledge can ever be produced independently of the researcher (Berger, 2015). As a white Western woman, I am not the target audience for the case study of DKDK (nor any maternal health communication material aimed at audiences in low-income countries) and therefore will interpret the film differently, from my own social situation. I have worked in media for development and health communication for a number of years, and this experience will undoubtedly mean that I have a positive bias towards such initiatives. I also had the advantage of having pre-existing relationships with some of the interview participants, which gave me access and a positive dynamic to the interviews. I have been conscious of the benefits and drawbacks of my employment and experience, and as such have aimed to identify any overt biases. The literature review which identified many criticisms of such initiatives has helped to address this.
Nevertheless, whilst there are limitations and challenges involved, these methods were felt to be the most appropriate to respond to the research questions.
Chapter 6: Results and analysis
This section of the research will respond to the three research questions, drawing on the theoretical framework, and data gathered from the interviews and content analysis.
Image: Health workers talk to the community about the importance of maternal health (Video still from DKDK)
The film itself2 is a high-quality, feature-length drama (duration of 1 hour and 36 minutes), and follows a community in a rural village. The main storyline is about the high number of maternal deaths in the community, which are in part due to the reliance on the TBA in the village and the lack of interaction with the health facility.
There are several main characters; the lead character and protagonist of the film, a young woman called Isha, her younger sister Fatima (who falls pregnant as a teenager), Isha’s husband (who at the beginning of the film is violent towards her but becomes more supportive and caring as the story develops), and the TBA and her assistant, who are shown as the villains of the story.
Throughout the film, several women (including Fatima) die in childbirth and are mourned by the community. Isha leads the village to take action to improve maternal health by drawing attention 2 A final draft of DKDK can be accessed here: https://vimeo.com/451181649/2d748c9999
to the plight of women, and seeking help from a local health facility who come and speak to the community members. The TBA is at first vilified but at the end is redeemed for her actions, as she agrees to work with the health facility and become involved with the referral process for pregnant women.
In addition to the main storyline about maternal health, the film interweaves themes of rape, domestic violence, alcoholism, as well as examining stereotypes around gender and village hierarchy. Though the main focus is on the transformation of the TBA, the whole community experiences collective behaviour change through a number of smaller actions.
6.1 Why is film an appropriate medium of communication for maternal health in Sierra Leone?
Film is accessible and novel
To respond to this question the analysis first defines what is an ‘appropriate’ medium of communication according to the identified literature. Scott writes that ‘ the aim of an M4D project is to design the most appropriate message, targeted at the most relevant audience, delivered through the most suitable media channels in order to promote desirable change in a particular behaviour’ (2014, p13).
In terms of message, this case study worked with the Ministry of Health & Sanitation and an external midwifery advisor to ensure that the content was medically accurate and in line with government policy. This is discussed in more detail in the analysis of the production process.
From the research undertaken by Wittels (2016) it is noted that literacy levels in Sierra Leone are low and any communication initiative should accommodate for this. The use of film therefore overcomes this barrier, however the research also notes that the modes of accessing information via media are mostly radio and SMS based.
The target audience for this case study, and indeed the most in-need audiences in Sierra Leone in terms of maternal health information, are those in rural settings. Scott notes that ‘ access to different media is sharply divided ’ between rural and urban settings (2014, p31). However the
model that FVFG offers is appropriate for the context; by bringing film screenings to rural areas through equipment that is portable and does not rely on mains power.
This case study challenges assumptions made by Manyozo, who writes on media for development as being problematic and notes that organisations are ‘ often outside of development problems’ (2012, p109). On primary and secondary stakeholders he writes that they do not live through development challenges (2012, p111) - this is not true for FVFG, who live amongst the audiences they aim to reach.
During the interviews it was also commented on that the novelty of having a film screening in a rural setting attracted audiences. FVFG distribution reports show that their film screenings attract audiences of 150 to 200 people. Jacoby et al note that an EE programme is ‘ more effective when
a “buzz” is created ’ (2014, p93). It is worth noting that there is an increasingly saturated market of media content due to globalization - currently FVFG have the advantage in cornering a market of audiences in rural communities in Sierra Leone, but this may be a challenge in future as access to media grows.
Film can address maternal health barriers
This analysis now addresses some of the key issues within maternal health in Sierra Leone and discusses why film is appropriate to help tackle them.
The first is the lack of health information that communities possess, which was highlighted by Wittels (2016). FVFG noted that whilst the government provides free healthcare for pregnant women, that ‘this information is not out there’ (personal communication, 5/11/20). Here film can
The second is health-seeking behaviours; the DMO noted ‘ poor health seeking behaviours,
especially in rural areas ’, stating that people often sought medical advice from traditional
healers (personal communication, 20/11/20). FVFG noted that there was an element of acceptance of maternal mortality; ‘ this is just destiny’ (personal communication, 5/11/20). The
DMO felt that ‘film helps in the area of the health seeking behaviour of the community and in improving community participation on health issues’ (personal communication, 20/11/20).
The third is any delays that are experienced during pregnancy and childbirth, as demonstrated by the Three Delays Model (Thaddeus and Maine, 1994). FVFG stated that ‘The most danger in maternal mortality in Sierra Leone is the delay… when there’s a complication - delay, when the woman it’s time to go to delivery - delay… this is something our film spells out over and over again clearly, because we know this is the most dangerous part ’ (personal communication,
5/11/20).
In relation to the above, sometimes delays in seeking health care can be due to the lack of involvement from male partners, who are often the decision makers in the household. FVFG noted that ‘You cannot blame the men because they also don’t know… they need the information
that my woman is as important as myself… especially when she becomes pregnant - she needs care and attention.... Make sure you do the right things like letting her go for check ups’
(personal communication, 5/11/20). From existing research on the use of film in health communication, it has been suggested that film is appropriate in targeting men, because they are more likely to be interested in receiving health information when delivered through film (Mweemba et al, 2020).
Drama is beneficial
That the case study utilises drama is also an appropriate method for communicating maternal health issues in Sierra Leone. Drama presents an opportunity to discuss sensitive information, or as Gesser-Edelsburg states ‘by creating a fictional boundary that protects the viewer, drama has the power to elucidate sensitive social issues’ (2014, p134),
Jacoby et al emphasise the importance of realistic and emotional storylines ‘ so that audiences
are able to relate to the story and reflect on their own behaviours ’ (2014, p84). In this instance, the use of drama humanises maternal mortality, rather than it being an abstract concept of statistics and numbers. The film shows the tragic loss of mothers, gives a visceral portrayal of grief, and demonstrates the impact of that loss on the members of the wider community. The CRM noted this in her interview; ‘ Just talking about numbers of people and talking mortality… but seeing a film like that where you can actually really see the impact on individual families… it's much more powerful’ (personal communication, 19/10/20). Gesser-Edelsburg notes that
‘drama can change positions and social conventions only when it manages to be ‘real’ for its spectators’ (2014, p137).
Green discusses the findings of narrative versus non-narrative messages, and in support of narrative messages notes that they have the benefit of ‘ transporting audiences and inducing them
to take the perspective of the protagonists ’, and that they ‘model appropriate attitudes and effective behaviours… narrative has the ability to win over an audience that would otherwise reject direct arguments against their social and policy convictions’(2021, p10). Similarly, Sowa
states that narrative messaging is likely to be more successful than non-narrative messaging (2018, p811). DKDK uses the benefits of drama and narrative to convey difficult issues to its audience.
Local content is valuable
This research argues that the case study of DKDK is appropriate and holds much of its success because it was an initiative of a local filmmaking group. As FVFG said in their interview (5/11/20):
‘We live in the community and no one can ever tell these stories better than us. These issues are real issues that affects our mothers, sisters, aunties and may affect our children's lives so we have the fire of passion to making sure something is done, and I don't see a stranger from the part of the world where things are exactly opposite to ours telling these stories with the same passion and truthfulness.’
This is supported by Manyozo who writes on the value of what he calls ‘indigenous knowledge communication systems’, describing them as ‘organic media for development approaches’ (2012, p95). Similarly Morris writes on the success of entertainment education when produced in local languages, and featuring local settings and situations (2005, p129).
This is also noted in the research on the use of film in health communication. Mweemba et al describe the positive audience reactions - ‘ people in the film are just like us… they resembled us, our skin’ (2020, p9). More importantly, because of this resemblance, the audience responded that they should emulate them. It was noted that if the films contained ‘ white people’ or ‘things from
overseas’ that ‘we were not going to bother with them’ (2020, p7). Similarly, Kumar et al highlight ‘that these videos are designed and produced in their hyper-local context is a large source of motivation and cause for engagement for our immediate target audience’ (2015, p8).
Film is trusted
Film can also have the advantage of being seen as a trusted source of information, that can be neutral yet authoritative.
The CRM described the advantages of film over a traditional health outreach activity that would involve a health worker coming in to speak to a community; ‘ particularly if you're coming and you're not from that community… it can feel quite judgmental… that you're saying that people will behave in this way or do these things and it's negative ’ whereas film is perhaps ‘less of a power imbalance, because it’s not that somebody is coming into the community as an expert ’
(personal communication, 19/10/20).
This is echoed by Kumar et al who analysed film’s effects on dismantling patriarchal values; that mothers in law were more willing to adopt new practices ‘ because [they] saw it on film’ (2015,
